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Decentralization of health services in Emrovia for improved performance of health systems GROUP 1 Background Middle income country with 30m people 10 health regions each with a regional health directorate (RHD) supervising 3-5 provinces

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background
Background
  • Middle income country with 30m people
  • 10 health regions each with a regional health directorate (RHD) supervising 3-5 provinces
  • Provincial health directorate (PHD) supervises: PG hospital, health centres & private sector
  • Three-tier HS: central, provincial & peripheral
  • MoH took policy decision to decentralize health services to better achieve HS goals
  • Issue: How best to decentralize to improve efficiency, equity & sustainability
  • In-depth system review undertaken by MoH & a team of experts
q1 most appropriate form of decentralization rationale
Q1: Most appropriate form of decentralization & rationale
  • De-concentration (of power to PHDs)/delegation
  • Why?
    • 3-tier health system already exists
    • MoH has a clear policy on decentralization
    • MoH has power for deconcentration & delegation but not devolution (which would require legislative action)
    • PHDs have financial, personnel, planning, monitoring, & IT capacities to efficiently manage services
    • PHDs have operational policies & procedures
slide4

Q2a: PROPOSED EXTENT OF DECENTRALIZATION OF VARIOUS FUNCTIONS

Finance

Central

Provincial

Peripheral

Rationale

Revenue generation

+++

+

+

To ensure equity in financial allocations

Allocation of resources to programmes

++

++

_

More financial authority to PHDs

Power of expenditure

+

++

++

Financial responsibility & accountability to service providers

Line item flexibility

-

-

-

Only MoF has authority to change

Income from fee & contracts

-

-

-

slide5

Q2b: PROPOSED EXTENT OF DECENTRALIZATION OF VARIOUS FUNCTIONS

Information & Planning

Central

Provincial

Peripheral

Rationale

Prepare annual plans

++

++

++

All levels need POAs

Processing & analysis

+

+

+

Each level should collect, analysis & use its information

slide6

Q2c: PROPOSED EXTENT OF DECENTRALIZATION OF VARIOUS FUNCTIONS

Service organization

Central

Provincial

Peripheral

Rationale

Hospital autonomy

-

-

-

MoH does not have powers for giving autonomy

Insurance plans

-

-

-

Does not exist in Emrovia

Payment mechanisms

+

+

+

- No change

- No info on payment mechanisms

Contracts with private producers

++

++

++

All levels to facilitate management of contracts closer to where services are provided

Local programs/norms

+

+

+

Shared responsibility

slide7

Q2d: PROPOSED EXTENT OF DECENTRALIZATION OF VARIOUS FUNCTIONS

Human Resources

Central

Provincial

Peripheral

Rationale

Recruit staff

+

+

+

Needed at all levels

Dismiss staff

+

+

+

Empower PHD & peripheral managers

Reward staff

+

+

+

Non-monetary rewards

Determine salaries

-

-

-

Set nationally

Relocate staff

+

+

-

Authority to PHD

Performance evaluation

+

+++

+

Best placed to evaluate them

Continuing education

+++

++

+

Concerns all levels

slide8

Q2e: PROPOSED EXTENT OF DECENTRALIZATION OF VARIOUS FUNCTIONS

Procurement And Logistics

Central

Provincial

Peripheral

Rationale

New equipment

++

++

+

Easier to identify needs at PHD & periphery

Drugs

++

++

+

Incentives for efficient prescribing practise at periphery

Repair & maintenance

+

++

++

Ease of identifying needs & contract management

q3 essential steps needed in preparation for decentralization
Q3: Essential steps needed in preparation for decentralization
  • Step 1: Health services mapping
  • Step 2: Binding ministerial decree establishing authority for decentralization to PHD
  • Step 3: Establishment of a policy and planning Committee
    • Review & disseminate operating policies & procedures
    • Develop & disseminate guidelines for roles and responsibilities (+ToRs)
    • Develop & disseminate an advocacy/communication plan targeting the management, HRH, and public
q3 essential steps needed in preparation for decentralization10
Q3: Essential steps needed in preparation for decentralization
    • Undertake capacities strengthening needs assessment & develop & implement a capacity building plan
    • Identify potential threats & mitigation strategies
    • Generate & disseminate pertinent research
  • Step 4: Establish a rigorous M & E system.